Nursing Elites

1. A client in the emergency department reports difficulty breathing. The nurse assesses the client’s appearance as depicted below: What action by the nurse is most important?

• A. Assess blood pressure and pulse.
• B. Attach the client to a pulse oximeter.
• C. Have the client rate his or her pain.
• D. Facilitate urgent radiation therapy.

Correct answer: A

Rationale: The correct action by the nurse is to assess the client's blood pressure and pulse. Difficulty breathing can be a sign of various conditions, including cardiac issues. Assessing blood pressure and pulse helps in determining the client's hemodynamic status and identifying any cardiovascular compromise. Option B is less crucial as attaching the client to a pulse oximeter may provide oxygen saturation levels but does not directly assess cardiac output. Option C is not the priority in this situation as the client's difficulty breathing is a more urgent concern. Option D is incorrect as urgent radiation therapy is not indicated based on the client's presentation.

2. The nurse is caring for a client following radical neck dissection and creation of a tracheostomy. Which assessment finding would indicate an immediate need for intervention?

• A. Frequent swallowing
• B. Presence of mucous membranes
• C. Bubbling in the water-seal chamber
• D. Inspiratory stridor

Correct answer: D

Rationale: Inspiratory stridor is the correct answer as it suggests airway obstruction, a critical issue requiring immediate intervention. Frequent swallowing (choice A) is a common postoperative finding and does not indicate an immediate need for intervention. The presence of mucous membranes (choice B) is a normal finding and does not require immediate intervention. Bubbling in the water-seal chamber (choice C) of a chest tube drainage system is an expected finding and indicates proper functioning of the system, not an immediate need for intervention.

3. Nurse Maria is preparing a care plan for a client receiving external radiation therapy. Which of the following interventions should be included?

• A. Use heating pads on the treated area
• B. Wear loose, soft clothing over the treated area
• C. Expose the treated area to sunlight
• D. Apply ice packs to the treated area

Correct answer: B

Rationale: Radiation therapy can cause skin irritation, dryness, and sensitivity in the treated area. Wearing loose, soft clothing helps minimize friction and pressure on the skin, reducing irritation and promoting comfort. The skin in the treated area is often more sensitive and vulnerable to damage, so this intervention helps protect the skin while maintaining the client’s comfort during the course of treatment.

4. A client has been prescribed epoetin alfa for anemia related to chemotherapy. What lab value should the nurse monitor to determine the effectiveness of this medication?

• A. Hemoglobin level.
• B. Hematocrit level.
• C. White blood cell count.
• D. Platelet count.

Correct answer: A

Rationale: Epoetin alfa is a medication used to treat anemia, particularly anemia related to chemotherapy or chronic kidney disease. It stimulates the bone marrow to produce more red blood cells, which increases the hemoglobin level. Monitoring hemoglobin is the best way to assess the effectiveness of epoetin alfa, as an increase in hemoglobin indicates that the body is producing more red blood cells and the anemia is improving.

5. The public health nurse is presenting a health-promotion class to a group at a local community center. Which intervention most directly addresses the leading cause of cancer deaths in North America?

• A. Monthly self-breast exams
• B. Smoking cessation
• C. Annual colonoscopies
• D. Monthly testicular exams

Correct answer: B

Rationale: In North America, lung cancer is the leading cause of cancer deaths among both men and women, and the primary risk factor for lung cancer is smoking. Therefore, promoting smoking cessation is a critical public health intervention that directly addresses this significant health issue. By helping individuals quit smoking, healthcare providers can significantly reduce the incidence of lung cancer and associated deaths, making this intervention a priority in cancer prevention efforts.

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